CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

breast_pump_medical_necessity_criteria

Defines medical necessity criteria and coverage for hospital-grade electric breast pumps (HCPCS E0604) under BlueCHiP for Medicare and Commercial products; excludes commercial/manual/electric pumps governed by a separate preventive services policy.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

Policybreast_pump_medical_necessity_criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is recommended and should be obtained via the insurer's online web-based tool for participating providers before obtaining a hospital-grade electric breast pump.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or policy content.

1Covered HCPCS code

2Medical necessity pathways

Coverage Summary

Hospital-grade electric breast pumps are specifically designed for reuse (sterilizable) and are intended for hospital use; they are not sold commercially. Manual and consumer electric breast pumps are addressed under a separate preventive services policy and are not the subject of this hospital-grade pump policy.

This policy defines medical necessity criteria and coverage for hospital-grade electric breast pumps (HCPCS E0604) under BlueCHiP for Medicare and Commercial products. Benefits may vary by group/contract; members should consult their Evidence of Coverage or Subscriber Agreement for applicable durable medical equipment benefits. Prior authorization is recommended and obtained via the insurer's online web-based tool for participating providers.

Medical Necessity Criteria

Medical Necessity Criteria for Hospital-Grade Electric Breast Pump

A hospital-grade electric breast pump is considered medically necessary when ONE of the following criteria is met:

Medical Necessity Criteria

Involuntary separation: There is an involuntary separation of an infant from its mother for more than 24 hours due to illness or injury of the infant.
Infant medical or congenital condition: A breast-feeding infant has a medical (for example, respiratory, cardiac or genetic condition) or congenital condition (for example, cleft palate) that interferes with breast-feeding.

ref": "b1_0

title":

Provider Actions & Billing Notes

Prior Authorization

Prior authorization recommended

Prior authorization is recommended and should be obtained via the insurer's online web-based tool for participating providers before obtaining a hospital-grade electric breast pump.

E0604

Documentation Required

Document medical necessity criteria

Providers must document which medical necessity criterion is met to support coverage — either an involuntary separation of the infant from the mother for more than 24 hours due to illness/injury, or an infant medical or congenital condition that interferes with breastfeeding.

E0604

Billing Rule

Rental period note

When covered, HCPCS code E0604 is billed as a rental; the policy notes a one-month rental period.

E0604

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

Policybreast_pump_medical_necessity_criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is recommended and should be obtained via the insurer's online web-based tool for participating providers before obtaining a hospital-grade electric breast pump.

SourceLink

On This Page

OpenPayer

breast_pump_medical_necessity_criteria

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions & Billing Notes

Definitions